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Anthrax has hit Glasgow: the story of a desperate hunt for its source

This article was taken from the August 2012 issue of Wired magazine. Be the first to read Wired's articles in print before they're posted online, and get your hands on loads of additional content bysubscribing online.

Scotland has an estimated 50,000 heroin users, many of whom can be found on the streets of Glasgow.

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Today, the signs of the city's drug problem are visible even in the city centre where addicts can be seen sitting on the pavement, leaning against walls and staring listlessly into the distance.

Hope House, a hostel for the homeless on the edge of the Clyde, provides a refuge for many of them.

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<p style="text-align: left;" class="p2">It was at this shelter that a 35-year-old heroin addict called Donny (not his real name) woke up on a December morning in 2009 with an unbearable pain in his thigh. On most days, Donny followed a familiar routine that had been engraved upon his life by his drug habit. He would walk over a bridge across the river to a neighbourhood on the opposite bank that was once a leper colony, and is now home to council housing. There, Donny would buy heroin from a dealer and visit his partner and two children. After taking a hit in their flat, he would wander back to his hostel. But on this day, Donny could barely walk. His thigh, right where he injected himself, was so inflamed that he had trouble dragging himself out of bed.

Donny's partner called an ambulance for him -- he would never have gone to the hospital by himself --and he was taken to the nearby Victoria Infirmary.

The doctors at Victoria -- as at other Glasgow hospitals -- were used to seeing heroin addicts show up with lesions in the arms, legs and other parts of the body where the users had been plunging a needle into their flesh. Such infections, the doctors knew, are typically caused by a bacterium called Bacillus cereus that is often behind food poisoning. But, when pathologists examined some of Donny's blood under a microscope, they saw a far more deadly germ. It was anthrax.

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Donny died on December 16, eight days after being admitted. By then, doctors at Victoria had already encountered another case like his -- a young female heroin user from the same part of town, with a festering lesion at her injecting site that was confirmed as an anthrax infection. The woman was responding to antibiotics, and doctors were confident that she would survive. But the two cases set alarm bells ringing among public-health officials who began calling other hospitals around town to find out if any other similar cases had been detected. By the end of the day, they had learned of three other patients who had been possibly infected: blood cultures would subsequently confirm them to be anthrax. All the patients were heroin users.

Colin Ramsay, an epidemiologist at

Health Protection Scotland in Glasgow, was about to leave work that evening when he got a phone call about the outbreak. Scottish authorities wanted him to lead a team to halt its spread and trace its origin. At a meeting of public-health officials, doctors and police officers the following day, Ramsay -- who is short and balding, with a silver-blond beard -- made a mental list of the questions that would have to be answered. It wasn't hard to guess that the infections were being caused by heroin contaminated with anthrax spores -- the oval-shaped vegetative form of the microbe that can survive extreme temperatures and lie dormant in the environment for decades, waiting for a host in which to germinate. But where did the contamination come from? Would the outbreak spread beyond Glasgow? And how could it be contained? The same questions were on the mind of others in the room, including a burly, moustachioed detective named Derek Robertson.

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Gallery: Anthrax has hit Glasgow: the story of a desperate hunt for its source

ByYudhijit Bhattacharjee

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Ramsay has an even tone that conveys a sense of certainty and assuredness. When he began looking into the outbreak, his first reaction was one of wishful thinking, the opposite of paranoia. "Well, it could be just these few cases, you know," Ramsay remarked to John Hood, a microbiologist at Glasgow Royal Infirmary. "I don't think so," Hood responded. "I think this is going to roll on."

It wasn't the first time that Ramsay had been called in to conduct a public-health investigation into anthrax. In 2006, he spent months trying to unravel the cause of death of a 50-year-old drum-maker in a village on the English border. A Buddhist who loved gardening, Christopher Pascal Norris suffered a brief flu-like illness before dying in an Edinburgh hospital. The cause of his death wasn't known until a month later, when blood samples were finally cultured at a lab in London, revealing the presence of Bacillus anthracis. The retrospective diagnosis left public-health officials worrying not just about the source of the infection but also about the likelihood that Norris's body may have exposed other people, such as postmortem technicians, to anthrax spores. Ramsay learned that Norris had been cremated. His remains had been scattered at his home, where a gust of wind had blown the ashes over everybody attending the wake, including a group of motorcyclists from Belgium. "We didn't know if the cremation was enough to get rid of the anthrax," Ramsay says. It took Interpol's help to track down the motorcyclists, and everybody exposed to the ash was put on antibiotics just to be safe.

Norris used imported goatskins to make African djembe drums. Ramsay knew of a few rare cases in the medical literature in which drummakers contracted anthrax infections from shaving animal hides embedded with spores of Bacillus anthracis. Investigators searched Norris's house for spores, but "it was clean as a whistle", Ramsay says. Then, after learning that Norris had joined a local drumming class a few months before his death, investigators had the three drums being used in the class sent to the UK's top infectious-

The hides on all of them tested positive for anthrax: each drum carried a different strain, one of which matched the strain that had killed Norris. Ramsay and his colleagues found anthrax spores at all the venues where the drums had been played, including the village hall. "It turns out that when you bang the drums, it liberates the spores from the surface of the skin," Ramsay says.

Norris contracted his illness from inhaling those spores.

Although Norris's death was a single, isolated incident that health officials analysed post-facto, the outbreak Ramsay was investigating was a tragedy still in the making. The first priority was to identify and treat victims as quickly as possible. Heroin users who showed up at hospitals with dark lesions and tell-tale signs of internal bleeding were taken to the operating theatre where surgeons cut away the infected tissue, in some cases removing kilograms of muscle and sinew from the patient's injection site. These so-called debridement procedures were not complicated, but the risk of infected blood drying in the operating room or anywhere else -- leading to the formation of spores -- put the outbreak-control team on edge. In one case, a surgeon forgot to put a tourniquet on a patient who was later confirmed as an anthrax case. The surgeon's overalls were splattered with blood. "By the time we found out about it, the blues that the surgeon had been wearing had gone through the hospital laundry along with other clothes," Hood says. "You know that the spores are not going to be destroyed by the hot water in the washing machine because it's not an incinerator or an autoclave." There was no way to trace those blues, and the control team ultimately decided that the risk was too remote for the hospital staff to have to track down the entire laundry batch and burn it.

To warn heroin users, Ramsay's team had leaflets distributed at homeless hostels such as Hope House and other venues frequented by addicts. The leaflets emphasised that there was no safe way to take the drug: users could end up being infected with spores even if they smoked contaminated heroin instead of injecting it. Addiction experts scoffed at the warnings. "The attitude was -- you're telling people who are addicted to a substance to stop using the substance they are addicted to," Ramsay says. "But what else do you do?"

As expected, the warnings did not help. By January 7, another 12 cases had been confirmed and the death toll had climbed to six. Like an eddying oil spill, the outbreak was spreading beyond Glasgow, with cases reported from the neighbouring regions of Lanarkshire and Tayside, and from as far as Stirling, 59 kilometres to the northeast of the city. The emerging pattern of cases was similar to an outbreak of Clostridium novyi -- another spore-forming microbe -- that occurred among Scottish heroin users in the year 2000. In that outbreak, just as in this one, there were almost no cases reported from Edinburgh, which is known to get its heroin through supply networks distinct from those that feed Glasgow.

Heroin users typically buy their drugs from neighbourhood dealers. The spread of the infections suggested a contamination in the region's entire heroin supply. "You couldn't get this [spread] of cases unless the contamination had occurred further up the distribution chain," Ramsay says.

The anthrax may have come from the poppy fields of Afghanistan, where the raw material for 90 percent of the world's heroin supply is grown. Alternatively, the contamination may have occurred after the poppy harvesting, at some stage in the manufacturing process, typically carried out at labs in Afghanistan and elsewhere. It may also have happened after the heroin entered Scotland: a trafficker may have stored it on a farm, burying it in soil contaminated with spores. Or the spores may have come from bonemeal, which dealers use to dilute heroin and increase their profits.

The Strathclyde police headquarters on Pitt Street is an imposing building located at the top of a hilly street. Inside, from his office on the fourth floor, Inspector Derek Robertson has a view of the city's south side. He is a big, friendly man with a beefy handshake. He points across the Clyde to the tower blocks of the Gorbals, where the first victims obtained their heroin. "It's got poverty, it's got violence, it's got heroin dealers," Robertson says. "If your dealer on the tenth floor doesn't have heroin, the dealer on the twelfth floor does."

Soon after officials became aware of the outbreak, Robertson was put in charge of the police investigation. Right away, he and fellow officers raided the residence of a dealer in Gorbals who had sold heroin to the first female victim, the one who got treatment the same week Donny died.

Nervous about contracting anthrax, the police entered the premises wearing heavy-duty breathing gear and suits meant to protect against chemical, biological and radiation threats. Later, when Robertson consulted the UK's top anthrax expert, microbiologist Tim Brooks, about the risk of officers becoming infected during such a raid, he realised that the protective outfits were overkill. "Tim said you'd have to have a big pile of heroin sitting on the table, and you'd have to puff it up and put your face in it. A standard face mask and gloves were all we needed," says Robertson.

Police searched the homes of several more dealers in Glasgow and other towns where cases were popping up. "We were going undercover in these areas to buy heroin,"

Robertson says. By the first week of February, a case had been detected in London. The Metropolitan Police hunted down the dealer, who had hidden the batch in a cereal box. They were confident that they had confiscated a tainted sample.

The police sent the seized and purchased heroin to the Centre for Emergency Preparedness and Response in Porton Down, where Tim Brooks runs a biosafety lab studying anthrax and other deadly pathogens. The spores could have been hiding anywhere in all of this material. To make sure they didn't miss any spores -- no matter how few there might be -- microbiologists at the lab divided the heroin into thousands of tiny samples to be tested individually. They dissolved each sample in citric acid, adding the solution to a broth used to culture microbes. The process was meant to free up any spores lurking in the sample, and encourage them to germinate. The Petri dishes were examined under a microscope the next day to see if any had grown Bacillus anthracis. It was a tedious task that occupied half a dozen people in the lab full-time for several weeks, Brooks says.

The lab tested what amounted to about 70,000 samples of heroin. Not one bit grew anthrax, not even the stash from the cereal box. The result was disappointing to the police, but not surprising. The number of cases was still very small compared to the population of heroin users in Scotland, which implied the contaminated heroin was likely to be a tiny fraction of the overall supply. To find any trace, the investigators would have had to round up a much bigger volume of the drug. "We could not afford to buy that much heroin," Brooks jokes, darkly.

In mid January, Ramsay and his colleagues learned of a heroin user in Aachen in Germany -- a few kilometres from the Dutch border -- who had contracted anthrax the previous December. "Up until this point, we were still considering the possibility that the adulteration had occurred somewhere in Scotland," Ramsay says. "After finding the German case, it was plausible that the contamination may have occurred well before the supply was split between Germany and Scotland." On February 5, Ramsay's office issued a press release laying out what they knew so far: "The anthrax contamination in both countries, thought to originate in the heroin supply, could share a source.

Days later, Ramsay recieved an email from a man who claimed to be a former prison inmate. "When I was in prison," the person wrote, "I met a Pakistani serving a sentence for heroin importation. One of the methods used was concealing drug shipments in containers transporting animal skins. Apparently Customs left these shipments alone because of the awful smell! I think that's where your anthrax contamination is coming from, in my humble opinion."

The most important clue to the origin of the contamination lay hidden within the pathogen itself.

There are dozens of strains of Bacillus anthracis that exist naturally in the world, with certain types being endemic to specific geographic regions. Scientists have also developed a variety of laboratory strains of the organism, some of which were created in decades past for use as bioweapons. All of these different strains are distinguishable by their DNA.

Ramsay and his colleagues turned to

Paul Keim, a tall, silver-haired microbiologist at Northern Arizona University in Flagstaff. Biologists and bioweaponeers used to think that anthrax DNA varied only a little from strain to strain. But in the late 90s, Keim and his colleagues identified more than 50 sites on the genome of Bacillus anthracis with variations. The work helped Keim to develop a DNA-fingerprinting test sensitive enough to distinguish between, for instance, a strain endemic to Kazakhstan and one found on livestock in Kenya.

Keim's lab maintains a repository of more than 1,000 samples; he was the researcher who identified the strain of anthrax used in the deadly 2001 attacks on US politicians and media outlets.

About a month after the outbreak began, scientists shipped samples of Bacillus anthracis cultured from the first victims to Keim. After extracting DNA, Keim's group began running assays. The researchers were quickly able to rule out all the known bioweapon strains, including one that the British military spread on Gruinard Island off the Scottish coast as part of a biowarfare experiment during the second world war. The researchers then screened the disease sample against strains from Afghanistan. No match there, either.

Their work continued into March, when Keim travelled to Porton Down to attend an unrelated meeting and to update the outbreak-investigation team. While he was there, he received an email from an undergraduate in his lab doing some of the DNA fingerprinting. She had found a match. The Glasgow strain was virtually indistinguishable from two anthrax isolates that had been sent to the repository a few years earlier by veterinarians in Turkey, collected from a couple of goats. "My heart rate went up,"

Keim says.

In a closed-door session with Brooks, Ramsay and law-enforcement officials, Keim started by drawing a diagram on the blackboard, a multipronged tree that showed the relationships among different anthrax strains. "I told them all the things that it wasn't," Keim says. The sense of relief in the room was palpable as he checked off bioweapons strains. A homegrown bioterror attack was effectively ruled out. Then, Keim revealed the match with the Turkish strains. The discovery of the Turkish connection led Ramsay's team to form a hypothesis. Drug users in Scotland, England and Germany were being infected by heroin that was contaminated while being smuggled through Turkey in an infected goat-hide.

The Turkish link fitted what is known about the movement of heroin into Europe: traffickers move the drug from Afghanistan and Pakistan into Iran, a major consumer of heroin, and into Turkey, before transportation into Europe. Much of the heroin destined for the streets of western and southern Europe is smuggled along the Balkan route, starting in Turkey and going through Greece and Albania, or through Bulgaria, Macedonia and a string of Balkan states. Travelling northwest, large quantities of the drug arrive in the Netherlands, from where it is distributed to the UK and elsewhere.

The police inquiry into the outbreak suggested that the tainted heroin had come in via this smuggling route, strengthening the hypothesis based on the genotyping work.

In January 2010, police had arrested a dealer in Kirkcaldy, near Edinburgh, who had sold heroin to a victim. That dealer led the police to a supplier one step up the supply chain who was being investigated for importing heroin from a group in Bradford. "This was the first tangible link where we thought we knew the route the drugs were coming in," Robertson says.

Meanwhile, police had infiltrated the Bradford syndicate, which was linked to a trafficking ring in the Netherlands. Four men were arrested in Bradford, and the Dutch police nabbed seven suspects. Through interrogations and available intelligence, investigators in Holland, England and Scotland confirmed that the heroin sourced by the Dutch ring had indeed travelled through Turkey.

In late March, a wave of new cases was reported in Dumfries, 85km southeast of Glasgow. Then the outbreak slowed down. Scottish authorities detected the final case in July, but the outbreak lasted longer in England, where the last case was in November 2010. By the end, the anthrax killed 13 out of 47 victims in Scotland, and claimed four out of five victims in England, in addition to a victim in Germany. "The most likely scenario is we were dealing with a single batch of heroin, and the contamination was the result of contact with a single infected goat, and that occurred in Turkey," Ramsay says. If there had been multiple batches wrapped in different goatskins, the cases would probably have involved more than one strain. Even though a batch would typically get distributed and used within weeks, the outbreak was drawn out over a year because the police inquiry after the first cases in Glasgow may have prompted dealers to shelve what they suspected to be contaminated and bring it out later, or to disperse it -- hence the spread across several cities. "We think all of the contaminated heroin has been used up or disposed of," Ramsay says.

In December 2011, Ramsay's team published a 134-page report on the outbreak. "I think it's highly unlikely we would get any more definitive evidence," Ramsay says. "Nobody tags heroin with a barcode."

On a rainy October night in 2011, Wired travelled two hours southeast from Glasgow to meet a woman who contracted anthrax after injecting heroin in March 2009. "Susan", now 32, had smoked heroin since the age of 23. She kicked the habit for a long period, returning some time in 2008. She was then on methadone -- a prescription opiate substitute -- but that wasn't enough. She said heroin helped her fight depression while she raised two children as a single mother, and it lessened the boredom of long-term unemployment.

A friend told Susan that injecting heroin would give a better high, and so Susan began injecting. "It just gave me the energy to go on," she explained. "To do the housework, to make the tea, to be in the proper frame of mind when the kids came back from school."

In March this year, after she had been injecting heroin into the muscle around her shins, she noticed angry red lesions. She'd heard about the outbreak in the news, but was too afraid to go to the doctor. One morning two weeks later, she was getting her younger son dressed for school when he swung his leg and accidentally brushed her shin with his shoe, making her whimper in pain and finally muster the courage to call her doctor.

She was admitted to a local infirmary where doctors removed two tennis-ball-sized chunks of tissue from her legs.

Two weeks after surgery, Susan felt a familiar craving. A dealer phoned. She went out and bought a bag for £10, returned home and filled up a syringe. Then, suddenly, she came to her senses. "I was sitting thinking, 'Oh my God, I nearly lost my life, this could be the same stuff that had the anthrax in it'," she tells Wired. "I squirted the syringe into a fag packet and threw everything away." Susan shows the deep hollows left in her shins by the surgery that saved her. "That's a constant reminder," she says, tears welling into her eyes. She is becoming used to not being able to wear either skirts or shorts, because her children were oblivious.

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Her scars had become an unfortunate symbol of the world's interconnectedness. A goat dies of anthrax in Turkey. A young woman in a small Scottish town must always wear trousers.